MASSIVE LIFEI-THREATENING LOWER GASTROINTESTINAL HEMORRHAGE FOLLOWING HEMORRHOIDAL Olaiide 0. Odelowo, MD, Getachew Mekasha, MD, and Mark A. Johnson, MD, Washington, DC

Hemorrhoids are common, and a significant proportion of patients who have experience symptoms such as bleeding, pain and itching. Endoscopic hemorrhoidal ligation is a safe and effective technique indicated for the treatment of grade 1 to 3 hemorrhoids, with a high success and low complication rate. Complications, when they occur, are minor and may include painful thrombosed prolapsed hemorrhoids, slippage of bands, minor rectal bleeding and chronic longitudinal ulcer. Rare, potentially life-threatening complications are massive hemorrhage and pelvic . A case of massive, life-threatening lower gastrointestinal hemor- rhage following endoscopic hemorrhoidal rubber-band ligation is presented. Our patient in- gested aspirin intermittently following the procedure. In a study documenting complications after hemorrhoidal band ligation, two of three individuals requiring transfusion for massive hemor- rhage were taking aspirin on a regular basis. The risk of massive hemorrhage after hemorrhoidal rubber band ligation is probably increased by ingestion of nonsteroidal anti-inflammatory drugs. It may be wise to withhold such drugs soon after the procedure, if feasible. U Natl Med Assoc. 2002;94: 1089-1092.)

Key words: * banding* rhoidal . More than 75% of persons in the bleeding * ligation United States have hemorrhoids at some time during their lives.' Symptoms due to hemor- INTRODUCTION rhoids affect up to 25% of the adult population Hemorrhoids result from abnormal dilata- in the US.' tion of the veins of the internal hemorrhoidal One of the modalities of treating hemor- venous plexus. This plexus is a network of the rhoids is rubber band ligation introduced by tributaries of the superior and middle hemor- Blaisdell in 1951.2 The technique was refined by Barron in 1963.3 Steigman and Goff, in the © 2002. From the Division of , Department of Med- mid-1980s postulated that elastic band ligation icine and Department of Surgery, Howard University Hospital, Wash- could be used to treat esophageal and gastric ington, DC. Direct correspondence to Olaiide 0. Odelowo, MD, varices if a device could be attached to the tip Division of Gastroenterology, Department of Medicine, Howard Uni- versity Hospital, 2041 Georgia Ave., NW, Washington, DC 20060; of a flexible gastroscope for deployment of phone (202) 865-1908; fax (202) 865-7268; or direct e-mail to bands.4 Endoscopic rubber band ligation of oodelowo©hotmail.com. is now in widespread use.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 94, NO. 12, DECEMBER 2002 1089 LOWER GASTROINTESTINAL HEMORRHAGE

The same device and technique is used for eradication of internal hemorrhoids. Severe complications such as bleeding and pelvic sepsis are rare following endoscopic homorrhoidal ligation, and the technique is relatively safe.5'6 Here, a case of massive, life-threatening lower gastrointestinal arterial hemorrhage fol- lowing endoscopic hemorrhoidal rubber band ligation, which necessitated transfusion of 20

units of packed red blood cells during the pa- ...... ::., tient's hospital course is presented. Figure 1. Close up view of the superior hemorrhoidal ar- CASE REPORT tery. A 52-year-old African-American male pre- sented with a two-hour history of the passage of bright red blood per . Massive bleeding bright red blood and clots per rectum every 10 made visualization impossible when rigid proc- to 15-minutes and worsening dizziness. He had tosigmoidoscopic examination was performed not experienced any or up to a point 20-cm from the anal verge. The prior to the onset of his symptoms. He had a initial Hb/Hct was 8.0/22.8; MCV: 94; plate- long history of symptomatic intermittently lets: 227; WBC: 10; PT: 15.2; INR: 1.59; PTT: 26; bleeding hemorrhoids for 20 years, and had Na: 140; K 3.9; Cl: 109; C02: 23; Bun: 11; Cr: undergone full with endoscopic 0.9; Glu: 111; Ca: 8.4; T prot: 5.7; alb: 2.8; T bili: hemorrhoidal rubber band ligation 17 days ear- 0.8; Alk Phos: 51; AST: 32; ALT: 17. The patient lier at another area hospital. Three bands were continued to pass clots and bright red blood deployed as indicated by the colonoscopy re- per rectum. After receiving 13 units of packed port. red blood cells within less than 15 hours, his He had experienced significant bright red Hb/Hct was 8.0/23.0. The patient was trans- bleeding per rectum three days earlier, and fused 10 units of fresh frozen plasma had received medical attention in the emer- A lower gastrointestinal bleeding scan re- gency room of another area hospital. He had vealed no evidence of active gastrointestinal left the hospital precipitously when the bleed- hemorrhage. The patient subsequently under- ing stopped spontaneously, and following re- went selective superior and inferior mesenteric suscitation with intravenous fluids. He had , which revealed active bleeding taken three tablets of buffered aspirin on the from the inferior aspect of the superior hem- day of the procedure after its conclusion 17 orrhoidal on the left, corresponding to a days earlier, and prior to the onset of the first site very low in the rectum (Figures 1 and 2). bleeding episode three days prior to admission No embolotherapy was performed because the to our hospital. site was easily accessible to surgical interven- On physical examination, vital signs were BP, tion. 105/66; P, 98; RR, 20; T, 97.3, and mucous Following angiography, the patient under- membranes were pale. The abdomen was soft, went rigid proctosigmoidoscopy with examina- there was no tenderness or mass noted, and the tion under general anesthesia. There was a 5 x bowel sounds were normoactive. There were 2 cm ulceration on the left, extending from the no stigmata of chronic liver disease. A rectal into the rectum. There were two examination revealed no perianal lesions or actively bleeding sites. One site was oozing on rectal mass, no obvious hemorrhoids, but the anal wall. A 3-0 vicryl suture was used to

1090 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 94, NO. 12, DECEMBER 2002 LOWER GASTROINTESTINAL HEMORRHAGE

tients experienced priapism lasting several hours, difficulty in urination, and tender indu- ration above the dentate line. Severe complications that required hospital- ization were observed in 13 patients (2.5%). Six of these patients had delayed massive bleeding, and seven had severe complicated of the hemorrhoid. Five of the six patients who had massive bleeding, had the onset of symp- toms 10 days or more after the procedure. Three of the six patients with massive bleeding Figure 2. View of the inferior mesenteric artery and the required transfusions. Two of the three pa- superior hemorrhoidal artery as a whole unit. tients who were transfused were taking aspirin regularly. suture ligate the site. Another site on the rectal Russel et al.6 documented four deaths fol- wall with pumping arterial bleeding was suture- lowing hemorrhoidal band ligation from bac- ligated with a 2-0 vicryl suture. The patient had terial septicemia or toxemia. a post-operative course without complications The patient in this case report had a massive or further bleeding. He was discharged three lower gastrointestinal hemorrhage, which re- days after admission. His Hb/Hct at time of quired transfusion of 20 units of packed red discharge was 10/31, after having been trans- blood cells 17 days after endoscopic hemor- fused 20 units of packed red blood cells. rhoidal ligation. This had been preceded by a smaller bleeding episode three days earlier, DISCUSSION which resolved spontaneously. A time interval Endoscopic hemorrhoidal rubber-band liga- of 10 days or more after hemorrhoidal ligation tion is considered a useful and safe technique is when sloughing of the ligated hemorrhoid with a very low rate of complications,5'6 and is seems to occur. This was the time period for recommended as the initial mode of therapy five of the six patients who had massive bleed- for grades 1 to 3 hemorrhoids.7 This patient ing in the study by Bat et al.5 A similar delay was had experienced intermittent bleeding per rec- seen in our patient. The magnitude of transfu- tum for 20 years, but the grade of the hemor- sion requirements for the three patients who rhoids prior to intervention is unknown. Since required transfusion, and the diagnostic details we did not perform the procedure, it is difficult of massive hemorrhage in the six patients are to know if there were any procedure-related not reported in the study by Bat et al.5 issues such as difficulties or faulty technique Hemorrhoidal rubber band ligation is a that may have led to this severe complication. treatment modality for grade 1 to 3 hemor- Bat et al.,5 documented a prospective study rhoids. Information regarding the grade of the of 512 patients who underwent hemorrhoidal hemorrhoids our patient had was not available. rubber band ligation over a seven-year period We may assume that the grade of the hemor- and followed up any complications. Successful rhoids, and his symptoms for several years, results were achieved in 82% of the patients. A made him a candidate for the procedure. total of 37 patients (7.2%) had complications. The use of aspirin by this patient may have Complications were minor in 24 patients been coincidental or have had a relationship to (4.7%) and included painful thrombosed pro- his presentation. He had taken three tablets of lapsed hemorrhoids in 11, slippage of bands in buffered aspirin later in the day after hemor- five, minor rectal bleeding in three, and rhoidal rubber band ligation and prior to ex- chronic longitudinal ulcers in two. Three pa- periencing the first episode of bleeding. Two of

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 94, NO. 12, DECEMBER 2002 1091 LOWER GASTROINTESTINAL HEMORRHAGE the three patients who had required transfu- ACKNOWLEDGEMENT sion in the study by Bat et al.5 were taking We thank Duane T. Smoot, MD, for reviewing this aspirin regularly. Aspirin and other nonsteroi- manuscript, and James S. Teal, MD, for advice regarding dal anti-inflammtory drugs (NSAIDs) inhibit the angiographic images. platelet production of thromboxane A2, an im- portant mediator of platelet secretion and ag- REFERENCES 1. Nelson RL, Abcarian H, Davis FG, et al. PrevTalence of gregation. Aspirin and NSAIDs are inhibitors benign anorectal disease in a randomly selected population. Dis of cyclooxygenase which converts arachidonic Colon Rectum. 1995;38:341-345. acid to a labile endoperoxide intermediate that 2. Blaisdell PC. Office ligation of internal hemorrhoids. is critical for thromboxane A2 formation. Aspi- Am JSurg. 1958;96:401-404. 3. Barron J. Office ligation of internal hemorrhoids. AmJ rin is the most potent agent, since it irreversibly Surg. 1963;105:563-570. acetylates the platelet enzyme so that a single 4. Stiegmann GV, GoffJS. Endoscopic esophageal varix li- dose impairs hemostasis for five to seven days. gation: preliminary clinical experience. Gastrointestinal Endosc. 1988. 34:113-117. The other NSAIDs are competitive and revers- 5. Bat L, Melzer E, Koler M, et al. Complications of rubber ible inhibitors with more transient effects. band ligation of symptomatic internal hemorrhoids. Dis Colon When thromboxane A2 synthesis is blocked, a Rectum. 1993;36:287-290. mild hemostatic defect occurs. Patients gener- 6. Russel TR, DonohueJH. Hemorrhoidal banding: a warn- ing. Dis Colon Rectum. 1985;28:291-293. ally have minimal symptoms such as easy bruis- 7. MacRae HM, McLeod RS. Comparison of hemorroidal ing and bleeding usually confined to the skin. treatment modalities. A meta-analysis. Dis Colon Rectum. 1995;38: Occasional patients will have prolonged oozing 687-694. 8. Handin RI. Disorders of the platelet and vessel wall. In: after surgery, particularly with procedures in- Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harison 's volving mucous membranes such as periodon- Principles of Medicine, 14th ed. McGraw-Hill Companies Inc.; tal, oral or reconstructive plastic surgery.8 1998:730-736. The slight elevation of the prothrombin time may have as well played a role in the severity of the bleeding. This patient may have had mild hepatic dysfunction from We Welcome Your with his history of significant alcohol ingestion, Comments which may well explain the prolonged pro- thrombin time. Journal of the National Medical Association welcomes your Letters to the Editor about CONCLUSION articles that appear in the JNMA or issues Hemorrhoidal band ligation is a safe and relevant to minority health care. effective modality for managing hemorrhoids. Address correspondence to Editor-in-Chief, This case report highlights a rare, potentially JNMA, 1012 Tenth St, NW, Washington, DC life-threatening complication. It may be wise to 20001; fax (202) 371-1162; or ktaylor avoid aspirin and other NSAIDs soon after @nmanet.org. hemorrhoidal rubber band ligation.

1092 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 94, NO. 12, DECEMBER 2002